Aetna 2013 Annual Report Download - page 43

Annual Report- Page 37
Other significant legislative and/or regulatory measures which are or recently have been under consideration
include the following:
• Amending or supplementing the Employee Retirement Income Security Act of 1974 (“ERISA”) to impose
greater requirements on the administration of employer-funded benefit plans or limit the scope of current
ERISA pre-emption, which would among other things expose us and other health plans to expanded
liability for punitive and other extra-contractual damages and additional state regulation.
• Imposing assessments on (or to be collected by) health plans or health carriers, which may or may not be
passed onto their customers. These assessments may include assessments for insolvency, uninsured or
high-risk pools, uncompensated care, Medicaid funding or defraying health care provider medical
malpractice insurance costs.
• Reducing federal and/or state government funding of government-sponsored health programs in which we
participate, including Medicare and Medicaid programs.
• Restricting or mandating health plan or life insurer claim processing, review, payment and/or related
procedures.
• Extending malpractice and other liability exposure for decisions made by health plans.
• Mandating coverage for additional conditions and/or specified procedures, drugs or devices (for example,
experimental pharmaceuticals).
• Restricting our ability to limit providers' participation in our networks and/or remove providers from our
networks (including in our Medicare, Public Exchange and other Commercial products).
• Regulating e-connectivity.
• Mandating or regulating the disclosure of health care provider fee schedules and other data about our
payments to providers.
• Mandating or regulating disclosure of health care provider outcome and/or efficiency information.
• Imposing substantial penalties for our failure to pay claims within specified time periods.
• Assessing the medical device status of health information technology (“HIT”) products and/or solutions,
mobile consumer wellness tools and clinical decision support tools, which may require compliance with
FDA requirements in relation to some of these products, solutions and/or tools.
• Imposing payment levels for services rendered to our members by health care providers who do not have
contracts with us.
• Enabling the creation of new types of health plans or health carriers, which in some instances would not be
subject to the regulations or restrictions that govern our operations.
• Imposing requirements and restrictions on the administration of pharmacy benefits, including restricting or
eliminating the use of formularies for prescription drugs; restricting our ability to make changes to drug
formularies and/or our clinical programs; limiting or eliminating rebates on pharmaceuticals; restricting our
ability to configure our pharmacy networks; and restricting or eliminating the use of certain drug pricing
methodologies.
• Creating, extending the life of or expanding state-sponsored health benefit purchasing risk pools, in which
we may be required to participate.
• Restricting the ability of health plans to establish member financial responsibility.
• Providing members the right to receive information about anyone who has accessed their electronic PHI,
even where such access was permitted (such as access by our authorized employees in the course of claims
administration or medical management).
Some of the changes, if enacted, could provide us with business opportunities. However, it is uncertain whether we
can counter the potential adverse effects of such potential legislation or regulation, including whether we can
recoup, through higher premium rates, expanded membership or other measures, the increased costs of mandated
coverage or benefits, assessments or other increased costs, including the cost of modifying our systems to
implement any enacted legislation or regulations.
Our business also may be affected by other legislation and regulations. The Dodd-Frank Wall Street Reform and
Consumer Protection Act (the “Financial Reform Act”) was signed into law in July 2010. The Financial Reform
Act creates incentives for whistleblowers to speak directly to the government rather than utilizing internal